Provider Demographics
NPI:1598215261
Name:MENDOZA, KIMBERLY ANNE (MS, LPC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 S 14TH ST. SUITE 140
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:46065
Mailing Address - Country:US
Mailing Address - Phone:682-888-6490
Mailing Address - Fax:
Practice Address - Street 1:200 S 14TH ST. SUITE 140
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:46065
Practice Address - Country:US
Practice Address - Phone:682-888-6490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71060101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional